| NPI | 1699012294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28790) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2013-01-16 |
| Last Update Date | 2013-05-12 |